The semi-structured interviews and FGDs were conducted in 12 schools including one boys only, three girls only, and eight co-educational schools. Altogether we interviewed 45 participants including 10 principals, 12 AEP teachers, 12 other teachers, and 12 students who had used counselling services (6 boys and 6 girls). We conducted 24 FGDs with students (14 with girls and 10 with boys), which involved 248 students; 2 FGDs each with SMs and TSMs, and one with supervisors.
Framework analysis helped in organizing the enablers and barriers to SEHER implementation under three overarching themes: stakeholders’ understanding of SEHER; SEHER intervention planning and implementation, and other issues in the implementation process. All the themes and sub-themes are discussed below.
Theme 1: Understanding of SEHER
Importance and relevance of SEHER in education
The most common enabler reported under the theme of understanding of the SEHER program by the interviewees (principals and teachers) from the SM-led schools, was the importance and relevance of SEHER in the education of students. These interviewees reported that schools are an ideal location to impart behavioural skills because most of the students do not have access to health and life skills education at home or elsewhere in their community. Participants said that educating young men and women on health and hygiene, emotional health and gender issues and rights, was a must given the poor health literacy, low marital age among women, and the high prevalence of violence and sexual abuse against women in India.
“SEHER provides important life-skills education to the students. In rural areas, young people don’t have supportive parents, especially girls who live in a strict environment…for them, the SEHER program provides an opportunity to access health education and life-skills.” [Teacher, SM school]
Conversely, the most common barrier observed in the TSM-led schools was the perceived lack of importance and relevance of SEHER in students’ education. The interviewed principals and teachers mentioned that providing education on health and life skills was not one of the duties of a teacher and it was burdensome implementing health programs in schools as they compromise teaching time.
“All the health programs in schools are shouldered by teachers… be it distribution of iron-folic acid tablets, AEP or SEHER…our primary job is teaching; teachers are not in the school to implement health programs.” [Principal, TSM arm school]
Understanding of SEHER’s intervention conceptualization
Another enabler related to the understanding of SEHER was the importance of a shared understanding of the program concepts by all the school community as a prerequisite for successful implementation. On the other hand, the interviewees from TSM-led schools mentioned that the lack of a shared understanding of the program concepts within the school community was an important barrier to successful planning and implementation of the SEHER TSM intervention.
The SM/TSMs were supposed to brief and engage with principals, teachers, and students in their respective schools about the intervention in the early stages of the planning and implementation process. However, most of the interviewees in the TSM-led schools reported that no orientation had been provided to them at the planning stage by the TSMs.
Interviewees from the SM-led schools reported that the monthly meetings held with the school staff by the SM and supervisor and the activities organized during daily assembly helped in creating awareness of the program. They described how the intervention was modeled on the pillars of building a positive school climate and designed to improve the capacity of the school to address the health needs of the students. They also mentioned that the students and teachers contributed to a participatory and democratic process of building a positive school climate. The interviewees also referred to the conceptual framework of the intervention and reported that the intervention aimed to provide factual information to students on health and well-being as well as impart life-skills such as decision making and problem-solving.
“We were told by the SM that the main objectives of SEHER are to improve social and problem-solving skills among adolescents, make the students aware of various physical and mental health issues and involve them in school activities. We were also briefed that all this can be done by improving the overall physical and social environment in the school.” [Female Principal, SM school]
Conversely, the principals and teachers from TSM-led schools reported not receiving any written information on SEHER from the TSM or visiting supervisor. This contributed to the lack of understanding of the objectives among stakeholders in these schools and created several challenges in the planning and implementation of the intervention.
“We were not briefed enough about SEHER. We should have been given complete information at the initiation of the program. I also feel that 2-3 copies of the SEHER manual, some handouts, brochures, etc. should have been kept in the school so that teachers could read and get familiar with the key concepts and activities of SEHER.” [Teacher, TSM school]
Students from both intervention arms were able to describe the SEHER program components and events. Students mentioned that SEHER aimed to provide information on a range of topics through assembly sessions, wall-magazines, and classroom interactions and to help them build skills such as decision making, problem-solving, communication, and interpersonal skills, anger management, time management, creative thinking, and public speaking.
“Through wall-magazine and assembly sessions, the SM sir provides us information on various topics like health, gender and violence, mental health, and substance use. He talks with us about some important skills like how to control anger; how to improve concentration and memorization; and how to make a decision and solve problems. This program helps us in building skills and I like it. The wall-magazine provides an opportunity to develop our creative skills like drawing, painting, and writing.” [Female student, SM school)
Theme 2: SEHER intervention planning and implementation
Three major sub-themes emerged as important facilitators or barriers to the successful planning and implementation of SEHER: roles and responsibilities of key stakeholders; collaboration and engagement; and governance and management.
Roles and responsibilities of key stakeholders
Two sub-themes surfaced when participants described the roles and responsibilities of key stakeholders: principal as a leader and SM and TSM as a facilitator of the intervention activities.
Principal as a leader: Since school principals have authority for the day-to-day operation of schools, their involvement in the program activities were perceived by the SMs and supervisors as essential to the acceptance and roll-out of SEHER. The principal’s acceptance, commitment, support, and ability to articulate the importance of the program activities and motivate and inspire other teachers resulted in the smooth implementation of program activities. The principal’s involvement examples included forming and organizing meetings of the School Health Promotion Committee, advising the SM and supervisor on solving students’ issues, creating a consensual plan of action to solve students’ concerns, and utilizing the school funds for purchasing school-level assets and equipment.
“…support by the school principal was very important. He was very much interested in this initiative and because of his interest, other teachers were also compelled to support SEHER activities. His strong leadership also translated into obtaining financial support for school development activities…everything can be done if the principal pays attention to the issues in the school.” [Female SM]
In contrast, the principals in the TSM schools reported that the TSMs preferred not to consult them in planning activities and reached out only when the students demanded changes in school infrastructure. Many TSMs felt that the principal nominated them to be the Teacher as SEHER Mitra to burden them with additional responsibilities. It was clear that the dynamics and lack of communication between the TSMs and principals led to poor relationship building and collaboration between key stakeholders (i.e., among TSM, principal, and teachers), which resulted in a poor buy-in and an impaired understanding of the SEHER intervention among school staff.
“When the program was planned, nobody consulted with us. At the school level, it was important to facilitate the distribution of different roles and build capacity among teachers however, no joint meeting was organized where principals and teachers were clarified about their role.” [Principal, TSM school]
SM/TSM as a facilitator of SEHER: The SM/TSMs were expected to act as the catalyst and facilitator of the building of a positive school climate and addressing student concerns through intervention activities. The SMs and TSMs were frequently reminded by the SEHER supervisors at the monthly meetings that their abilities to listen, assess, enable, and build trusting relationships were core skills that would lay the foundation for facilitating the planning, implementation, and evaluation of this collaborative approach.
Principals and teachers mentioned that the fact that the SM was able to work full-time to drive SEHER program activities was an enabler of successful implementation in their respective schools. They appreciated the SM’s enthusiastic nature and passion for working with students. They also said that, under the guidance of experienced supervisors, the SMs organized numerous activities throughout the year, which helped in establishing a supportive environment for students. Principals also acknowledged the additional duties shared by the SMs such as preparing students for competitions, assisting the school staff during examinations, and assuming the responsibilities of a librarian or arts and craft teacher.
“Dialogue between teachers and students has increased since SEHER has started in our school. There are many opportunities for the students to interact with the teachers…every month there is some celebration or competition, which has improved the interaction between students and teachers.” [Female teacher, SM school]
Students perceived the SM as someone who was ‘friendly’, approachable, and deeply interested in addressing their concerns. Students mentioned having faith in the SM who could help them in solving problems while maintaining confidentiality. Students also valued their experiences of engaging with the SM in fun activities, which were not part of their regular studies but helped them to gain knowledge and skills.
“I was going through a personal problem. My parents wanted to stop my education and get me married. I was disturbed due to this fact and couldn’t concentrate on anything. I did not know what to do so I went to SM sir. He patiently listened to my problem and assured me that nothing of that sort would happen. He asked me whether I would be okay if the principal talked to my parents, which I thought was an okay thing to do. My parents were called to the school. Our principal and SM sir discussed this issue with my father a couple of times and my parents agreed to continue my education and not to think about my marriage before I complete grade 12 education”. [Female student, SM school]
The supervisors and SMs reported about the significant efforts invested by the supervisors and project team in integrating the SM into the school and gaining the acceptance and support of the school community. These efforts included organizing regular meetings with the staff, involving teachers in planning and implementing competitions, leading the daily school assembly, and assisting the principal in non-academic duties.
“In the initial year, the response from the teachers and staff was lackluster; in some incidences, they created hurdles. However, as time passed, the SMs started helping out teachers in their duties, attending classes when teachers were not able to do so; started helping out in the day-to-day activities of the school, for example, organizing daily assembly, helping teachers during exams, preparing and escorting students for inter-school competitions, assisting in administrative tasks, and so on. This all helped in accepting the SMs as a member of the school.” [Male Supervisor]
On the other hand, the TSMs mentioned that not having dedicated time and resources to deliver the program hindered the program implementation in their schools. They could not fully perform the role of the SEHER Mitra due to ancillary academic (e.g., deputation for evaluation of answer sheets, cluster meetings, etc.), non-academic (e.g., deputation for elections), and administrative duties (e.g., preparation and submission of monthly attendance reports of students) given to them. They also raised concerns about the program creating additional work for them without providing any monetary incentives.
“We are overburdened with responsibilities such as clerical work, preparing documents for the distribution of all the student voucher schemes, etc. We are also sent to election duty, examination duty, cluster meetings, etc. On top of that, teachers implement programs like AEP and SEHER. We are not given any incentive or recognition for doing this extra work.” [Male TSM]
The TSMs also mentioned that attempts made by them to undertake a coordination role and to encourage teachers to implement activities were met with some resistance.
“In this school, students have flooded the speak-out box complaining that teachers do not attend the classes regularly and the school schedule is not followed-up. I organized a meeting with the principal and teachers to discuss these issues. Instead of suggesting changes, many teachers accused the students of not being interested in learning. Teachers were reluctant to change their practices.” [Female TSM]
Students mentioned that they were confused about the dual role of the TSM, who was a regular teacher in the classroom and performed as the SEHER Mitra during program activities. Many students expressed concerns about sharing their issues with the TSM as they thought the TSM would not respect confidentiality and share their issues with other teachers; a few students also reported incidents where confidentiality had been breached. Many female students expressed their hesitation to seek help from a male TSM. Students also complained about the unavailability of the TSM in the school due to other engagements.
“I could not share my problem with him [the TSM]. I felt uneasy to discuss something personal with him. I wondered what he would make out of it. I was not sure if he would keep it only with him or would share it with other teachers. Nevertheless, I approached him for help. He listened to me carefully but as we were sitting in the teacher’s room, there was a lot of disturbance. Constantly someone was entering the room, I was not comfortable during those meetings.” [Female student, TSM school]
Some students also mentioned that during the peer group meetings, the TSM did not listen to their suggestions and took the decisions on major concerns independently.
“We wanted to access the books in the library during school hours. We suggested to him that the peer group members in each classroom could take the responsibility of distributing them at the beginning of the class and collecting them at the end of the class. He did not agree with it and said it was not possible.” [Male student, TSM school]
Collaboration and engagement
Collaboration and networking within the school: In the SM schools, the interviewees acknowledged that the democratic and participatory approach used by the SM to facilitate the intervention planning and implementation was the key contributor to successful implementation. They mentioned that the mapping exercise and meetings with staff and peer-groups were crucial strategies in understanding the needs of the students and generating and implementing the action plan.
“We) were always asked to share our opinions. For example, if there was a function to be organized on someday, she (the SM) would ask how we want to celebrate it, or if there was a common complaint in the speak-out box, she would ask us the ways to solve it. Our opinion was also taken into consideration while making a decision.” [Male student, SM school]
Teachers from the SM schools appreciated that it was for the school to analyze its reality and find solutions to the school-level problems. Consequently, when teachers consulted and involved in decision-making, the resulting SEHER activities were viewed more favourably.
“We were all asked if there was anything that we wanted to include in SEHER activities for the second year. [This was] an opportunity to give our ideas to improve the program; this was very new. This has never happened in any other program.” [Female Teacher, SM school]
In contrast, the lack of internal collaboration and networking efforts from the TSMs was a barrier to the implementation of intervention activities in the TSM schools. The TSMs reported that the principal and teachers were not keen to incorporate program activities in the daily schedule of the school due to accumulating academic and non-academic pressures. On the other hand, principals and teachers from the TSM schools mentioned that the TSM never sought their advice to implement program activities.
“Most of the teachers were reluctant to participate in the program activities…there is a culture in Bihar, if someone is doing something good then instead of supporting, people prefer to create obstacles…I am also a teacher so not blaming other teachers…the system is broken; it requires a fix. The education department needs to invest in training teachers to change their attitude and build a supportive culture.” [Female TSM]
Student engagement: Interviewees from the SM-led schools mentioned that students were engaged in program activities due to the relevance and multiple benefits to them (i.e., personal, social, and academic) as well as the participation in the decision-making process. Student engagement, mainly through making posters, flyers and banners, presenting skits, and participation in meetings, pivoted on a perception that the program was both fun to take part in and addressed a perceived knowledge and skills deficit.
“SEHER has been a great fun… competitions, classroom debates, or role-plays in the assembly… there was so much to learn for all the students. I got a chance to try my skills in public speaking, writing, and painting through various competitions. The SM provided us study tips and counselling was available to those students who had personal problems.” [Female student, SM school]
There was an overwhelming consensus among students from the SM-led schools that the success of SEHER was due to the initiative actively involving and empowering students. Students mentioned that prompt action on students’ issues increased their faith in the SM and participation in intervention activities. They cited that the program was successful at bringing students and teachers together to have stimulating conversations on students’ concerns, which they would normally not associate with classroom teaching.
Contrary to this, students from TSM arm schools felt that the lack of student inclusion in the decision-making process hampered program implementation. They voiced that their schoolmates were nervous to participate in activities such as designing the monthly wall-magazine, competitions, whole-school assembly activities, and peer club meetings. They also mentioned that most students stopped participating in SEHER activities because the school did not take any action on the complaints shared by them through the suggestion box.
“…we were told that students could share their concerns through the suggestion box, so we kept complaining about dirty toilets; non-availability of fans; and not having enough benches in the schools. No action was taken by school...nobody asked about our suggestions.” [Male FGD participant, TSM school]
Parental involvement: The interviewees from the SM-led schools considered the efforts to involve parents in the School Health Promotion Committee (SHPC) were beneficial because it allowed the formation of a nucleus to initiate the process of change in the school. For example, in one SM school, the issue of open defecation around the school boundary and on the school ground was discussed in one of the meetings and hence, the parents took the lead and talked with the local leaders and community members to resolve this issue. Parents’ involvement was also regarded as important because it opened up a dialogue between the school management and parents regarding discipline issues in schools.
“In every meeting, he [the SM] would ask whether parents have any ideas to put forward, what would they like to discuss, or any particular activity they would like to organize or follow-up on. He would talk to all the committee members individually, and that helped to bring more parents to the school.” [Female teacher, SM school]
The lack of parental representation and engagement in the SHPC was a commonly reported barrier across the TSM-led schools. The TSMs believed that there is a lack of a culture of collective participation in all spheres of society and schools are no exception to it. The school teachers complained that parents visit the schools only when there is a distribution of vouchers or free goods.
Governance and management
The SEHER intervention makes a few recommendations aimed at providing a coherent and sustainable infrastructure for intervention implementation. Thus, at an individual school level, each school was expected to establish the SHPC comprising representatives from the entire school community. The objective of this committee was to drive the program and ensure that it was rolled out in an effective and relevant way. It was thought that the SHPC would be more likely to take ownership of the program, thereby promoting program relevancy and sustainability. In SM-led schools, the principals followed the development and implementation of the SHPC. These committees understood their role in reviewing the priorities identified by the students and discussed and acted on the possible ways to address these priorities. However, in TSM-led schools, the SHPCs never functioned to their fullest potential due to resistance from school management from the outset. Most of the school principals expressed concerns, that assuming responsibility for SEHER governance and management would create additional workload pressures for staff. These concerns were legitimate given the additional academic and non-academic responsibilities assigned to the teachers. However, this reluctance to embrace the establishment of a SEHER support infrastructure also reflects the lack of clarity around the understanding of the program and the absence of a sense of ownership by the school management and shared agreement on roles and responsibilities in the TSM schools. Furthermore, the program tended to be seen by members of the school community as an add-on to school services rather than an overall framework and ethos embedded within existing school structures.
“Every school was supposed to set up a Committee through which the school would decide the priorities for the school. This committee would come up with solutions for the students’ concerns. However, in most of the TSM schools, this committee was formed as a formality. Parents were reluctant to visit schools and principals were not enthusiastic enough. This resulted in poor execution of this component and enough pressure was not built to implement activities which could have changed the school’s ethos.” [Male Supervisor]
Other issues in the implementation process
Readiness of schools
A key consideration in the exploration and planning stage of implementation was an assessment of the ‘readiness’ of the setting. It was evident from a range of interviewee responses that many broader factors had posed an obstacle to successful SEHER implementation in the TSM-led schools. For example, principals reported that without time and resources including human, financial and material, it is futile to implement a program. Principals also mentioned the budgetary restrictions by the Department of Education (DoE) to use the school development fund for improving the school infrastructure was an obstacle. The interviewees from the TSM arm schools also mentioned that the DoE is implementing multiple programs when the schools are understaffed. The TSMs mentioned that complementary actions were required between the program staff of the AEP, Going-to-School program, and SEHER, to generate a holistic plan to address the actual needs of the students, which was more likely to succeed in the context of Bihar.
“The government does not want to take responsibility for long-term initiatives…the education system in Bihar is chaotic…multiple programs are being implemented in schools through teachers but nobody in the government thinks of one program...this is a challenge of the bureaucracy.” [Male Principal, TSM school]
Fidelity issues
The process evaluation of SEHER during the implementation period indicated that the coverage of intervention activities was better in SM-led schools relative to TSM-led schools. This highlighted the importance of the Standard Operating Procedures developed to guide the implementation of each component of the intervention being followed. Some TSM-led schools tended to implement their version of intervention activities. Thus, the program was initially based on the individual views of how the program would be delivered rather than the evidence-based health-promoting school practices which underpinned it.
“The guideline on peer-group formation mentions that an election method should be followed to select peer-group members. Instead, in some schools, the TSM selected the members. Similarly, the manual describes the steps to be followed to read and discuss the wall-magazine issues in a classroom setting, however, very few TSMs followed these guidelines.” [Male SEHER supervisor]
Support from the Department of Education: Principals and TSMs perceived that the lack of Departmental monitoring, technical assistance and support for SEHER negatively affected its implementation. They complained that DoE officials never visited the schools to review the program activities, coordinate activities with other school-based programs, follow-up with the TSMs or recognize the additional responsibilities shouldered by the TSMs and teachers to implement the program. According to the principals, the involvement of the DoE is necessary to understand the challenges faced by the schools in bringing about change. However, there were no efforts from the DoE officials to reach out to the principals and understand the ground-level situation.